Laserfiche WebLink
fja <br /> r <br /> JUN28 <br /> QUALITYTESTING OF UNDERGROUND 7ANKSATAFFiURDABLERATES' <br /> WR(WART H <br /> Post OKice Box 36 Thornton, Ca 95686 (209) 794-0102 Ff1�fERNU!6CE <br /> General <br /> ` In'form., atn <br /> Facility Name: ��Zay <br /> Bldg.No <br /> .: <br /> Site Address: )1d City: k0o y zip: <br /> Facility Contact Person: G <br /> t°\ 1 r Vt <br /> —�� Contact Phone No.: ( ) <br /> Make/Model of Monitoring System: f-& '�R D Dy Date of Testing/Servicing: �-- <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea ro date boxes to indicate eci6c a ut ment inspected/serviced: <br /> Tank ID: 1if 1-- Tank ID: IV <br /> O In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> (RICsiner,, <br /> lar Space or Vault Sensor. Model: pWar Space or Vault Sensor. Model: <br /> mmg Sump/Trench Sensor(s). Model: 3 ( e ipmg Sump/Trench Sensor(s). Model: <br /> 13 F]1.Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> echanical Line Leak Detector. Model:�A"/.rf Ulgechaaical Line Leak Detector. Model: <br /> 13 Electronic line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify ui ment type and model in Section E on Pae 2). 1 ❑ Other(specifv equipment and model in Section E on Page 2). <br /> Tank ID: Tank ID: <br /> E3In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: U Annular Space or Vault Sensor. Model: <br /> 17 Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: <br /> U Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: 13Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(Specify equipment a and mode]in Section E on Page 2). El Other(specify ui ment type and model in Section E on Pae 2). <br /> Dispenser ID: Dlspenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model' <br /> 11 Shear Valve(s). Ll Shear Valve(s). <br /> ❑ Dis user Containment Float(s)and Chain(s). ElDis enser Containment Float(s)and Chain(s). 4,+ <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> 13 Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). 1] Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: <br /> Ll Shear Valve(s). ❑ Shear Valve(s). <br /> ODis user Containment Float(s)and Chain(s). 17 DiseSaser Containment Finials)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this formInclude information for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this infunnation is <br /> correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): 1]System set-up ❑Alarm histery report <br /> Technici�attName(print): A f-(y//-`!tCC% <br /> Signatw e: <br /> Certification No.: 0l;' �...ry License No.: <br /> Monitoring System Certification <br />